Surgery in times of COVID-19: Issues and Safeguards

The three-week lockdown starting 25 March does not prevent resurgence after its suspension. The models suggests that a single lockdown of more than 44 days will reduce expected case numbers below 10. Thus a longer period of lockdown extending beyond 21 seems inevitable and advisable.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), it was first identified during an investigation into an outbreak in Wuhan, China.

COVID-19 disease manifests itself with fever, cough and difficulty in breathing. 50% of these patients may also present pre-dominant digestive symptoms (lack of appetite, loose stools, vomiting and abdominal pain). World Health Organization(WHO) has declared COVID-19 as a Public Health Emergency of International Concern (PHEIC) which has till date affected 197 countries/ territories including India. WHO characterized COVID-19 as a Pandemic on 11 March 2020. Taiwan’s scientists had pointed to WHO as early as 31 December,2019 about the human to human transmission of the virus.

Social distancing and other non-pharmaceutical interventions have proven to be effective tools in most pandemics. On 24 March, the government of India ordered a nationwide lockdown for 21 days. Forecasts of the COVID-19 epidemic in India with mitigatory social distancing in various scenarios of lockdown have been attempted using mathematical models. The three-week lockdown starting 25 March does not prevent resurgence after its suspension. The models suggests that a single lockdown of more than 44 days will reduce expected case numbers below 10. Thus a longer period of lockdown extending beyond 21 seems inevitable and advisable.

Do Indians have advantage in fighting this pandemicIndians comparatively carry more Natural Killer (type of white blood cell) which controls viruses. These cells were acquired as a result of living in an environment challenged with more infective agents. So there is proof that we have a stronger innate first line defense. BCG vaccine is given in Indian children to modulate immunity against tuberculosis. BCG vaccination has been variously shown to reduce 30% of viral infections, with the help of this Innate immunity. A single study in China also found that the virus transmission is best at a temperature of 8.72 degree Celsius and every 1-degree increase, reduces the transmission rate. The warm temperature which we experience, may thus decrease the transmission rate. Though WHO mentions that the evidence so far suggests that the COVID-19 virus can be transmitted in areas with hot and humid weather. Also, observation in the current pandemic is that mortality is less still in malaria endemic areas.

India has been criticized for its poor record of testing people to diagnose COVID-19. That, however, is set to change, with the ready availability of kits at affordable price points.

Caring for the caregivers: protection for Healthcare Professionals

In all of this, the message is clear- Stay home, be safe. But there are many whom the country needs now more than ever, including healthcare professionals. We need healthcare workers to care for the expected surge in patients. How do we keep them attending to patients rather than becoming patients and carriers of the disease themselves? They should wear full-body protective gear, including goggles, complete head coverings, N95 particle-filtering masks, and hazmat-style suits. Do we have adequate supply of all the protective gear? Government has promised adequate supply, but it doesn’t seem to be enough. So what happens when a healthcare worker is exposed to a COVID-19 disease patient without adequate protection? They have to be sent home for home-quarantine. Think of it, if every healthcare worker who come in contact with COVID-19 is sent for home-quarantine, we may have none.

Protection in Operation Theaters

There are other set of healthcare workers who are presented with the dilemma of what to do in these unprecedented times. Do they go ahead and take toxic hydroxy- chloroquine for prophylaxis of SARS-COV-2 infection as recommended for high risk population? 80% of patients with COVID-19 have mild symptoms or are asymptomatic. Then there are false negative tests! If these false negative or asymptomatic carriers are operated on, the virus can spread in the operation theater (OT). These viruses live for 72 hours on metal and plastic. These virons after getting sucked by the exhaust fan, will blow into the OT as aerosol by HEPA filter/Ventilation system. The fumigation of the OT should be able to eradicate this threat.

Also, there is an expected rush of COVID-19 patients which necessities allocation of valuable resources towards managing these patients. This has prompted cancelling of elective surgeries the world over. The need to safeguard themselves and their patients has prompted the surgeons to develop their own protocols to tide over the pandemic situation. The decision for surgical care should be based on surgeon’s own surgical and clinical judgment and assessment of resource availability. Patients should get the surgical care based on practice of evidence based medicine. Non-operative line of management is advised when it is clinically appropriate for patients, specially looking at risk and benefits of surgery. In case of a modicum of doubt, surgical teams should consider waiting for COVID-19 test results of patients who may be suspected of being infected. In case of anticipated OT staff shortage, emergency surgical procedures specially in the night should be considered only after ascertaining suitable availability of staff and equipment. Aerosol is generated during procedures such as intubation, electrocautery of blood, catheter insertion etc. This increases the risk of healthcare workers acquiring infection from patients who test COVID-19 positive or patients who are on high suspicion of having infections. If these procedures are unavoidable, surgical staff should wear personal protection equipment including disposable surgical caps, medical protective mask (N95), work uniform, disposable medical protective uniform, disposable latex gloves, full-face respiratory protective devices or powered air-purifying respirator.

The noble profession of surgeons and healthcare professionals is still able to motivate them to attend to their work unfettered. With the case count rising around, what they need is to adopt best care practices and learnings from the experiences of colleagues from across the world to safeguard themselves and in turn, their patients and family.

DISCLAIMER: The views expressed are solely of the author and ETHealthworld.com does not necessarily subscribe to it. ETHealthworld.com shall not be responsible for any damage caused to any person/organisation directly or indirectly.

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